RESUMEN
OBJECTIVES: We evaluated the respective influence of the causative pathogen and infection site on hospital mortality from severe sepsis related to community-, hospital-, and intensive care unit-acquired infections. DESIGN: We used a prospective observational cohort 10-yr database. We built a subdistribution hazards model with corrections for competing risks and adjustment for potential confounders including early appropriate antimicrobial therapy. SETTING: Twelve intensive care units. PATIENTS: We included 4,006 first episodes of acquisition-site-specific severe sepsis in 3,588 patients. INTEVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included 1562 community-acquired, 1432 hospital-acquired, and 1012 intensive care unit-acquired episodes of severe sepsis. After adjustment, we found no independent associations of the causative organism, multidrug resistance of the causative organism, infection site, or presence of bacteremia with mortality. Early appropriate antimicrobial therapy was consistently associated with better survival in the community-acquired (0.64 [0.51-0.8], p = .0001), hospital-acquired (0.72 [0.58-0.88], p = .0011), and intensive care unit-acquired (0.79 [0.64-0.97], p = .0272) groups. CONCLUSION: The infectious process may not exert as strong a prognostic effect when severity, organ dysfunction and, above all, appropriateness of early antimicrobials are taken into account. Our findings emphasize the importance of developing valid recommendations for early antimicrobial therapy.
Asunto(s)
Antibacterianos/uso terapéutico , Causas de Muerte , Farmacorresistencia Microbiana , Sepsis/tratamiento farmacológico , Sepsis/mortalidad , Choque Séptico/tratamiento farmacológico , Anciano , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/microbiología , Infecciones Comunitarias Adquiridas/mortalidad , Cuidados Críticos , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Bases de Datos Factuales , Femenino , Bacterias Gramnegativas/efectos de los fármacos , Bacterias Gramnegativas/patogenicidad , Bacterias Grampositivas/efectos de los fármacos , Bacterias Grampositivas/patogenicidad , Mortalidad Hospitalaria/tendencias , Humanos , Unidades de Cuidados Intensivos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Medición de Riesgo , Sepsis/microbiología , Índice de Severidad de la Enfermedad , Choque Séptico/microbiología , Choque Séptico/mortalidad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Middle-ear barotrauma (MEB) is one of the most common side effects of hyperbaric oxygen therapy (HBO2). The incidence of MEB has been shown to vary between treatment centers and patients. This study was aimed to determine which patients are at high risk of MEB. MATERIALS AND METHODS: Prospective study including all the patients treated in a multiplace HBO2 chamber between January and December 2005. Scoring of MEB before and after HBO2 by otoscopy was performed using the Haines and Harris classification. RESULTS: We included 130 patients: 53 Males, 37.5 +/- 20.5 years old; 76% were treated for CO poisoning, 11% for iatrogenic gas embolism, 12% for decompression sickness and 4% for necrotizing soft tissue infection. 13% were intubated. MEB occurred in 13.6% of the patients (12.4% of the conscious and 24.4% of the intubated patients, p = 0.26). Risk factors for MEB were: repetitive treatments and difficulties with pressure equalization. There was no influence of age, sex or mechanical ventilation on the occurrence of MEB. CONCLUSIONS: MEB induced by HBO2 occurred in 13.6% of the patients. There is no difference in incidence when comparing intubated and non-intubated patients. In non-comatose patients, difficulties with equalizing pressure were predictive of MEB.